GIFT OF Founaatlon in IJursing =

'^^.ciur.r.fA nr>

TEXTBOOK OF

SURGICAL NURSING

•Th5^) THE MACMILLAN COMPANY NEW YORK DALLAS

•

CHICAGO BOSTON ATLANTA SAN FRANCISCO •

MACMILLAN & LONDON

•

•

•

CO.. Limited

BOMBAY CALCUTTA MELBOURNE •

THE MACMILLAN

CO. OF TORONTO

CANADA, hvo

TEXTBOOK OF SURGICAL NURSING

BY

RALPH

COLP,

A.B., M.D., F.A.C.S.

\

LECTURER INSTRUCTOR IN SURGERY, COLUMBIA UNIVERSITY, NEW YOltK IN SURGICAL NURSING. MT. SINAI HOSPITAL TRAINING SCHOOL FOR SENIOR ASSISTANT Sl'RGEON, BEEKMAN NURSES, NEW YORK STREET HOSPITAL, NEW YORK; ADJUNCT SURGEON, FORMERLY MT. SINAI HOSPITAL, NEW YORK LECTURER IN NURSING AND HEALTH, TEACHERS COLLEGE, COLUMBIA CNn^ERSITY, NEW YORK ;

;

;

AND

MANELVA WYLIE KELLER, CHIEF OPERATING ROOM NURSE, ST. HOSPITAL, NEW YORK, AND ANESTHETIST, LUKE'S HOSPITAL, NEW YORK, AND MOBILE HOSPITAL NO. 2,

•'ORMERLY

A. B. F.,

l!5eto

B.S., LUKE's ST.

FRANCE

^ork

THE MACMILLAN COMPANY 1926 All rights reserved

R.N

1

PlflNTEDMll THE. l/NJTED STATES OF AMERICA

^

.i3RARY

(y^yf-u^-i^^fiiifiA^i^

Copyright, 1921,

By the MACMILLAN Set

up and

electrotyped.

COMPANY

Published June, 1923

December,

Reprinted

1922

May,

1923

October,

1923

"

" '

192

May,

September,

192i 1926 September, 1926 Javiiarii.

"

tress of ji.

J.

Little

New

&

York.

Ives

U

Company S.

A

/

/

DEDICATED IN RESPECTFUL TRIBUTE TO THE

COURAGEOUS AND DEVOTED NURSES

WHO

SACRIFICED THEIR LIVES TO THE

CAUSE OF SUFFERING HUMANITY IN

THE GREAT WAR

e:SS8o:i

PREFACE The

authors have endeavored to present as accurately and

as simply as possible for the pupil nurse the actual detailed

nursing of the various conditions related to things surgical.

The various procedures are based on the technic employed in hospitals throughout the country, and therefore the book will be found useful as a text in training schools generally without regard to local conditions.

It

presupposes a thorough

knowledge of the elements of practical nursing.

The funda-

mental treatments, as a rule, have been carefully learned in the probationary periods, but a thorough understanding of the

underlying principles of surgery and the necessary surgical nursing are often wanting.

While

it is

true that

all

orders are given by the surgeon, and

executed with dispatch and accuracy by the nurse, the time has

passed when the nurse was a mere automaton.

She must know

the ante- and post-operative care required for

all

the patients

coming under her supervision. The complete management of an operating room, as w-ell as the conversion of a private home into a suitable place for surgical procedures, should be thor-

oughly understood, and an operation by name, be sectomy,"

"thyroidectomy,"

should immediately

summon

or to

it

"glos-

" choledochotomy, "

mind

etc.,

the condition and the

The nurse should be well acquainted with the recent surgical developments of the World War, such as the Carrel-Dakin method of wound disinfection, the ambrine treatment for burns, and the suspension treatment for fractures,

technic involved.

since her aid

is

essential for their proper accomplishment.

The chapter dealing wdth Surgical in the main, pital,

New

on the diet

York.

to the Surgical

We

lists

Dietetics has been based,

used by the Presbyterian Hos-

are indebted, for the photomicrographs,

Department of Columbia University, and for

PREFACE

viii

some of the pictures to the "Manual of Splints and Appliances, Medical Department, United States Army."

The authors wish

to express their appreciation

and thanks

to Miss F. Evelj^n Carling, Assistant Superintendent of Nurses,

New

York, for her advice and many sugRalph Colp, and Mrs. Amy P. Phillips for their keen interest and invaluable assistance in the prepSt.

Luke's Hospital,

gestions,

and

to Mrs,

aration of this volume.

INTRODUCTION AND HISTORY Surgery is as old as human needs. There have always been wounds and broken limbs, and human ingenuity has always endeavored more or less successfully to relieve the sufbleeding

fering so occasioned.

In ancient times, the supposedly super-

natural secrets of the healing art were zealously guarded from the laity,

and not

till

the Greek Hippocrates in 460 B.C. wrote

his surgical treatises did surgery pass ence.

from mysticism

to sci-

So keen were the observations of Hippocrates that some and dis-

enthusiasts claim that his two works on fractures locations are in

many

respects unsurpassed even to-day.

until as recently as four centuries ago very little tiie

And

was added to

storehouse of surgical knowledge.

During the early Christian era and tte Middle Ages,

sur-

many different classes of society, by by monks and nuns, by the famous Arabian

gery was practised by friars

and barbers,

The universifrom the very beginning prohibited research of any kind and demanded that every procedure be justified by the authority of Galen. Now and then solitary thinkers tried to find out things for themselves by observation and reflection. The court physicians, and by ladies of noble birth. ties

great occupation of the majority of the people was warfare

and much of the its

little

progress in surgical knowledge owed

inspiration to the necessities of war.

king's armies the

new

But even

to aid the

truths learned by experience and ob-

servation were discountenanced

by the

faculties of the uni-

In spite of this opposition, by the fifteenth and sixteenth centuries there was a widespread awakening of the free versities.

scientific spirit.

It

manifested

itself in

the forming of groups

and experiment in physics, chemistry, anatomy and physiology. Tremendous progress was made in all the sciences. Harvey discovered the circulation of the blood, the to study

i>

INTRODUCTION AND HISTORY

X

microscope came into use, and Fahrenheit invented the ther

"Western Europe broke out

mometer.

that outshine

tlie

utmost

scientific

of Greece," says H. G. Wells

j

into a galaxy of

names

reputations of the best age

and

of these Vesalius

lopius, the anatomists, are especially

and Fal-

honored by surgeons of

to-day.

By

the eighteenth century, private dissecting rooms and ana-

tomical laboratories were flourishing.

However, the surgeons

themselves of this period neither helped nor shared in this great advancement of science.

untutored

lot,

The barber-surgeons were an

ready to make use of a few tricks of the trade

The task remained to place the practice and this was one of the many good deeds which make the name of John Hunter shine out in the history of surgery. "More than any other man he helped to make us gentlemen," a contemporary said of him. Through for practical gain.

of surgery on a high plane,

the efforts of Dr. Hunter, the already existing companies of

barber-surgeons were forced to study anatomy,

comparative

anatomy and physiology, and thus the surgical profession by the right of hard and regulated study began to take rank with the high order of scientists.

Public

museums

of

anatomy and

physiology were founded; the method of clinical teaching Avas

adopted; and in the beginning of the nineteenth century the

day of painless operation had come wdth the discovery of anesthesia. Still

The dark ages when

the surgeon was held in disrepute.

investigation

was forbidden were passed;

all

the sciences aided

the surgeon; he progressed wdth the great advance in anatomy,

physiology and pathology.

And

yet, the

tion

was

in truth a sad affair.

No

nical skill of the surgeon, patients,

of blood poisoning.

Now and

matter

where he

hospitals

operated were considered houses of certain death.

how

An

more often than

then a

opera-

great the tech-

wound did

not, died

heal without

formation of pus, but both spontaneous and operative wounds almost invariably became infected, with death as the result. So common was this, particularly in hospitals, that many surgeons feared to operate at all. The term "hospitalism" was coined by Sir James Y. Simpson, who collected stathe

INTRODUCTION AND HISTORY

xi

tistics proving that private patients were far less liable to succumb from operation than those treated in hospitals. With the advent of Lister came "a lij^ht that brightens more and more as the years give us ever fuller knowledge," as Sir

William Osier has the

One

said.

It

was

to the researches of Pasteur,

great French scientist, that Lister

owed

his

inspiration.

of the first practical results of Pasteur's studies on fer-

mentation and spontaneous generation was a great transformation in the practice

and

It is not too

results of surgery.

much

to claim this as one of the greatest boons ever conferred

on

Let us quote from Lister's paper on the subject

luimanity.

which appeared in the London Lancet, 1867.

"Turning now

to the question of

how

duces decomposition of organic substances,

thrown upon

of light has been

the researches of Pasteur,

convincing evidence that

this

the atmosphere pro-

we

find that a fliood

most important subject by

who has demonstrated by thoroughly

it is

not to

its

oxygen or to any of

its

gaseous constituents that the air owes this property, but to

minute particles suspended in low forms of

life

it

which are the germs of various

long since revealed by the microscope and re-

garded as merely accidental concomitants of putrescence, but

now shown by Pasteur

to be its essential cause, resolving the

complex organic compounds into substances of simpler chemical constitution,

just as the yeast plant converts sugar into

and carbonic acid." From Lister's w^ork modern surgery takes

alcohol

whole subject of wound

its rise

and the

infection, not only in relation to sur-

gical diseases but also to childbed or puerperal fever

now forms

one of the most brilliant chapters in the history of Preventive

So great have been the results of Lister's work that

Medicine. it is

indeed almost

difficult

from our fortunate position of to-day In

to glimpse the sad position of the surgeons of his time.

present-day hospitals surgical infection and puerperal fevers are almost things of the past, and for these achievements alone the

names of Louis Pasteur and Joseph Lister

posterity as Lister's

among

work

will go

down

to

the greatest benefactors of humanity.

Avas the

beginning of antiseptic surgery.

Sur-

geons at last learned to combat with a strong antiseptic the

INTRODUCTION AND HISTORY

xii

germs which

wound, the room, the surThe black-robed, professoriallooking surgeon of earlier times was succeeded by a surgeon clothed in immaculate white. For an operation in the true Listerian style, the part to be operated on was first of all enveloped two hours before the operation in a towel soaked in Incarbolic acid, to destroy the germs present in the skin. struments and sponges lay for a half hour in a flat porcelain exist in the air, the

geon's hands, his instruments.

dish of carbolic acid.

Towels soaked in this solution covered

and blankets near the part to be operated on. The hands of the surgeons and nurses were thoroughly washed in the same solution. The operation itself was performed under a cloud of carbolized vapor from a steam spray producer. Then a strip of oiled silk, coated with carbolized dextrin and further washed in carbolic lotion, was placed over the wound and over this was applied a double ply of carbolic soaked gauze, covered with eight layers of dry gauze. Finally came a thin mackintosh cloth, and this whole apparatus was covered with a gauze bandage. The mackintosh cloth served to prevent the carbolic acid from escaping and at the same time permitted the discharge from the wound to spread through the gauze. The vapor given off by the carbolic gauze shielded the wound and the surrounding parts from septic contamination. These conditions were very strictly maintained until the wound was the tables

healed.

All these cumbersome and complicated measures a bit unnecessary to us

;

especially

may we

made

sigh

may seem

when we

re-

hands red and

flect

that the use of carbolic acid

raw.

Some surgeons produced

strict

cleanliness without following the whole Listerian tech-

nic.

Gradually, Lister himself gave up most of these meas-

ures,

much

bolic acid

to the

which

Lister's

excellent results

by methods

of

advantage of the patient, for that same car-

so effectively destroyed pathogenic bacteria in

and about a wound, also invariably injured the exposed tissues. The great achievement of Lister was not the spray and gauze method but the conclusive proof that cleanliness is the most essential factor in successful operating.

To the

antiseptic surgeon of 1867 has succeeded the aseptic

INTRODUCTION AND HISTORY surgeon of to-day. water to

sterilize all

xiii

and hot materials in the operative procedure, and

The

aseptic surgeon uses steam

not only does he carefully scrub his hands, but he also renders

them absolutely germ-proof by wearing rubber gloves which have been previously sterili/.ed by boiling water and steam. Such is the simple aseptic method which has been gradually evolved from the Listerian antiseptic system. The spray producer has almost passed into oblivion but the spirit of Lister's teachings

— scientific

cleanliness

—

still

guides

the

surgeon's

work.

In the World AVar aseptic surgery proved of cause almost

all

The wound

wound

little avail,

wounds were contaminated and

be-

with pus.

filled

of the battlefield is not similar to the operative

of the civilian hospital.

ciency, before those

wounded

in

Even with the utmost modern warfare can be

effi-

con-

veyed to the nearest surgical station much time will have To deal elapsed with ample opportunity for contamination. with these conditions, the antiseptic method was revived. time, however, the strong carbolic acid of Listerian

This

fame was

replaced by an agent harmless to the tissues, the Carrel-Dakin Solution. est,

This solution

is

not merely one of historical inter-

but widely used by surgeons of to-day for a certain type of

wound, and

it

will be discussed in detail in

Chapter XIX.

To-day the vision of surgery is glorious. The surgeon is everywhere recognized as an indispensable worker in the community. The growth of a highly competent, scientifically trained nursing staff has more than doubled the good results of his work.

Nurses have indeed existed from

earliest Chris-

tian times; they have either been gentle, noble-minded Sisters of

Mercy

hospitals.

in the convents, or uneducated, inefficient

maids in

Neither of these classes was what could be called

trained or educated according to the present view of what

The first trainwas established as recently as 1836. This Kaiserswerth, Germany, is the mother of the

training and education should be for a nurse. ing-school for nurses little

school at

present system; within

its

walls Florence Nightingale acquired

her practical knowledge of nursing in a few months' time.

Miss Nightingale was a

woman

of genius

and

vision.

During

INTRODUCTION AND HISTORY

xiv the Crimean ion

by

tary

its

War

the

London Times roused British public

opin-

vivid account of the terrible conditions in the mili-

ho.s])itals of

the

war

zone,

and Miss Nightingale

set out

for that region with a staff of trained nurses to superintend

and wounded. was of greater importance

the care for the sick plished

What to

she actually accom-

humanity than nursing She applied the

individual soldiers stricken in the Crimea.

and brought and order out of indescribable chaos and misery. The "lady with the lamp" at Scutari showed what a hospital should be and what scientific nursing should mean. Although her work in the Crimea was done more than a score principles of hygiene to hospital administration

light,

cleanliness

of years before Lister 's revolution in surgery, Miss Nightingale 's

administration and management was based on the Listerian idea of scientific cleanliness. And out of her work in the Crimea arose trained nursing on a large scale. In 1860 the modern hospital school system was inaugurated by her in Great Britain at St. Thomas's Hospital, London. The dignity of the nursing profession has thus been raised it has become a calling for superior women, wuth the recognition of the need for a rigid education and training before revolution in hospital building,

;

the nurse can call herself a "graduate."

Just as surgeons

were made "gentlemen" by the work of John Hunter, so nurses through the efforts of Florence Nightingale were

made

"ladies," and their profession put on a very high plane of social usefulness.

Fund

In the same decade that the Nightingale

founded world.

at St.

That

School was

Thomas's, Lister's great work was given to the

is,

the rise of

modern surgery

is

contemporaneous

with the beginning of a careful, trained nursing body.

This

more than an historical coincidence, for since that time the increasing demands of medical and surgical knowledge have

is

well nigh revolutionized the nursing craft.

To-day the sur-

geon in the operating room of the hospital, or in the private home has come to rely absolutely on a highly educated and trained nurse.

To her he

leaves the preparation of supplies, the

preparation of the operating room and instruments, and the preparation of the patient; she even assists the surgeon in the

INTRODUCTION AND HISTORY operation

many

itself in

care of the patient

need that the nurse ity to

fill

and must

ways.

is left fills,

up

finally,

most of the after

entirely to the nurse.

a need that will

She

a greater sphere. live

And

is

the

xv

It is

a great

grow with her capac-

Handmaid

to that high social calling

of Surgery

by being well pre-

pared; she must be so educated and trained that she will not be a mere automatic

worker,

filled

and heart

to the

work that

the history of surgery surgical nurse still

a

new

but an intelligent, enthusiastic co-

tool,

with a zeal for science, and giving her whole mind

one,

is

is

is

before her

— for

only recently in

there scientific surgical nursing.

a pioneer

;

the trail has been blazed

and she must show what she can

do.

;

but

The it is

TABLE OF CONTENTS CHAPTEU

PAGE

Introduction and History I.

II.

ix

Pathology

3

Shock and Hemorrhage

14

Tlie treatment of shock, transfusions, the treatment of hemor-

rhage. III.

Post-Operative Complications Nausea, vomiting, pernicious vomiting, tympanites,

auto-intoxication,

pulmonary embolism, urinary

20

gastric dihxtation, post-operative pneumonia, retention, urinary suppres-

sion, phlebitis, thrombosis, hemophilia.

IV.

The Surgery and Surgical Nursing of the Alimentary System

V.

38

The Surgery and Surgical Nursing

op the

Glandular

System V'l.

v'll.

72

The Surgery and Surgical Nursing of the Nervous System

The Surgery and Surgical

Nursing

op the

Osseous

System VIII.

87

The Surgery and Surgical Nursing of the Reproductive System

105

IX.

The Surgery and Surgical Nursing of the Respiratory System

X.

The Surgery and Surgical Nursing op the Skin and Appendages

XI.

III.

120

130

The Surgery and Surgical Nursing of the Urinary System

XII.

80

142

Surgical Dietetics

151

Anesthesia

173

Preparation of the patient; care of patient during anesthesia; after care.

XIV.

XV.

Arrangement, Organization, and Equipment op the Operating Theatre The rooms and their furnishings; the personnel; supplies.

193

Operating Room Sterilization

232

Definitions; the agents; practical methods.

XVI.

The Operating Room in Action Preparation of the room for the operation; preparation and sterilization of the operative field

;

operative positions and

draping; the operation; after the operation. xvii

263

TABLE OF CONTENTS

XVlll

CHAPTER

XVII.

PAGE 296

Instrument Passing Representative operations; drains.

XVIII.

XIX.

The Dressing of the Wound

313

The Carrel-Dakin Treatment What the system is; history; equipment;

321

of the system;

XX.

tlie

Dakin

the four processes

solution.

Bandaging

355

Definitions, uses of bandages, forms of bandages, materials used for bandages, sizes of bandages, principles of bandaging, modes of applying the roller bandage, the application of bandages to the various parts ol the body, miscellaneous special bandages, the fastening of the bandage, miscellaneous bandaging rules, the removal of roller

bandages. .^XI.

Operations in the Home The steps in the preparation and management, improvised

399

operative positions.

Appendix

415

Solutions; weights and measures; equivalent thermometer scales; abbreviations and symbols.

Index

437

LIST OF ILLUSTRATIONS PAGR

FIO.

Microscopic drawing of an incised wound twenty-four hours old

5

2.

Microscopic drawing illustrating the growth oi fibroblasts along the fibrin of the blood clot

6

3.

Microscopic drawing of granulation tissue

7

4.

Microscopic drawing of an infected wound

5.

Microscopic drawing of a deep abscess

6.

Types of

7.

Colostomy before

8.

Colostomy bag

61

10.

Tube "en chemise" Methods of applying traction

95

11.

Traction leg splint

12.

Traction

13.

Jones wrist

14.

Lane

15.

Wyeth

1.

9.

intestinal

arm

....

8 and 9 „

11

54

anastomoses

being incised

61

64

96 and 97

splints

.

99

100

split

101

plate

pins

103

16.

Tracheotomy tube

123

17.

Brewer empyema tube

18.

An

127

easy and safe method of lifting a helpless patient

.

.

181

19.

Restraining sheet for patients recovering from an anesthetic

20.

Suitable instruments for grasping the tongue

21.

Mouth gags

22. 23.

Two Two

24.

Adjustable instrument table

199

25.

Wheel

200

26.

Carrying stretcher

27.

Stretcher suitable for carrying patients up and

28.

Seat for the anesthetist or surgeon

29.

Bench for the surgeon

30.

Hand

31.

Dressing drum with pedal opening standard

32.

Hot towel drum with pedal opening standard and

33.

Instrument

34.

Utensil sterilizer

of the

....

.

183 185 186

more elaborate types of operating table

.

.

.

197

199

varieties of instrument table

stretcher

200

to stand

down stairways

200 201

upon when the operating table

can not be adjusted suitably in height

201 202

light

equipped steaming device

202 electrically

203 203

sterilizer

204 xix

LIST OF ILLUSTRATIONS

XX

PAOB

FIO.

35.

Hot and

36.

cold water sterilizers

205

37.

Wash basins Two types of arm

38.

Amputation retractors

39.

Muslin apron

215

40.

Operating caps

216

41.

Culture tubes

217

42.

Glove cover

219

43.

Two Two

220

44. 45.

Face masks

46.

207 208

basin

214

tjpes of hip or pelvic rest

221

types of irrigator stand •

.

.

.

222

49.

Abdominal pads Laparotomy sheet Lithotomy towel Steam jjressure dressing

50.

Hot

51.

The Mayo soldering iron cautery

52.

Electric cautery

53.

55.

The Paquelin cautery Needle book Method of rolling a catgut suture

56.

Factory prepared catgut in hermetically sealed glass tube

57.

Dorsal position

58.

61.

Method of fastening the arms at the patient's side Method of fastening the arms on the chest Laparotomy sheet in place for an abdominal operation Draping for the dorsal position with two sheets and four towels

62.

Two

63.

Trendelenburg position

64.

Shoulder guard for keeping the patient in place in the Trendelenburg position

271

65.

Gall bladder position

(with table rest)

272

66.

Gall bladder position (with broken table)

273

67.

Kidney position

274 275

47. 48.

54.

59. 60.

224

227 230 238

sterilizer

242

air sterilizer

»

...

243 243

244 253

255

or ligature .

261

267 .

•

.

.

.

268 269 269

270

270

types of towel clamps

271

68.

Prone position

69.

Latero-prone position

276

70.

Eeversod Trendelenburg position

276

71.

Sims

showing the use of one sheet for draping

.

.

277

72.

Lithotomy position, showing the use of the table stirrups

.

.

277

73.

.

278

74.

Draping with a sheet and towels in the lithotomy position Draping with the lithotomy towel and stockings for

75.

Breast position

76.

Method of draping the hand and forearm for the breast opera-

position,

.

the

lithotomy position

tion

279 280

281

LIST OF ILLUSTRATIONS

xxi PAOE

FIG.

77.

Draping for breast position

78.

Detachable arm board supplied with the table

79.

Simple long narrow board wliich may be an arm board

80.

ITse of stirrups for operations

81.

Draping for leg operations

28.5

82.

Draping for a face case

285

83.

Arrangement of patient in the prone position on a special head rest for operations upon the back of the head or neck

84.

Folded towel clamped about the face to protect the operative

85.

field from the inhaler in face, neck, or skull operations The Kocher guard adjusted and draped so as to isolate the

86.

Portable dressing stand

290

87.

Diagram of the arrangement of the instrument stand when the type shown in Fig. 24, page 199 is used

299

88.

Intestinal

89.

Drains

90.

Portable metal dressing box

314

91.

Portable electric instrument sterilizer

315

upon

tlie

....

fitted to

281

282

any table as 283

leg

284

.

.

.

.

anesthetist in operations upon the neck

286 287 289

and stomach clamps

303 311

....

92.

Dressing carriage for use in the hospital ward

93.

Adhesive plaster and tape device for holding dressings in place and allowing their removal without the disturbance of the

94.

Dressing forceps for use in dressing the Carrel-Dakin wound

95.

The rubber delivery tubes

96.

Eeservoirs for the Dakin solution

97.

Glass syringes for administering the Dakin solution

98.

Stopcocks for use on the supply tubing in the reservoir method of administering the Dakin solution

327

99.

Glass connecting and distributing tubes

327

316

317

plaster

.

.

324 325

"

326 .

.

.

326

100.

Glass dropper tube for use on the main supply tube in the reservoir continuous method

328

101.

The way

to perforate the

329

102.

The way

to lay the vaseline

the

wound tube gauze strips around the margin of

wound

336

103.

Four positions of wounds with the appropriate wound tubes in them

104.

Diagram of

105.

Arrangement of the apparatus for the reservoir method of

106.

Suggested ways of branching the main supply tube so that it can feed the tubes of more than one wound, or widely scattered and variously grouped tubes in the same wound

possible ways of making exits through the gauze and cotton pad for the wound tubes so that they need not lie on the skin surface, and will remain where they were placed when the wound was dressed

337

339 340

instillation

.

.

34]

LIST OP ILLUSTRATIONS

«jxii

PAGE

no.

107.

Arrangement of the screw stopcock and the glass dropper tube on the main supply tube for the reservoir continuous method

108.

Method

109.

Dr. Carrel's bacteriological chart

110.

The

111.

Two methods

112.

The triangular bandage, or

113.

Many-tailed bandages

114.

Method of making The way to grasp

342

of instiilation

115.

connecting inaccessible wound tubes to a supply tube for the syringe method of instillation

117. 118.

119.

single .

343

.

346

bandage

roller

ing 116.

of

356

of rolling a

bandage by hand

358

plaster of Paris

the

357

sling

roller

359

....

bandages

361

bandage preparatory to apply366

it

The way to begin the application of the roller bandage The circular mode of bandaging the usual anchorage for the applied roller bandage

367

The spiral mode of bandaging The wrong mode for the part (the

368

.

.

—

mode

spiral

367

for a conically-

shaped part)

369

124.

The way to make a reverse The figure-of-8 mode of bandaging The recurrent mode of bandaging Completed recurrent bandage Spiral bandage of the finger anchored

125.

The thumb

126.

Complete bandage for the hand and arm

127.

Reverse figure-of-8 bandage

128.

^lethod for securing tapering part

129.

Heel bandage

377

130.

Complete bandage for the foot and leg

378

131.

132.

The eye bandage Double eye bandage

380

133.

The ear bandage

380

134.

The Barton bandage

135.

Two methods

136.

Double roller bandage for the application of the bandage

137.

The way

138.

The

139.

The shoulder spica bandage varied

140.

The Velpeau bandage

385

141.

The breast bandage

386

142.

The double breast bandage

386

143.

The hip spica bandage

387

120.

121. 122. 123.

figure-of-8

spica

369

370 371 372 to

the

wrist with

a

and a circular turn

374

374

spica

better

375 375

anchorage

of

a bandage

a 376

379

381

of bandaging the cheek, temple, or chin

to use the double roller

on

.

.

382

recurrent

bandage

bandage of the shoulder

383 383

384 to cover the axillary region

385

LIST OF ILLUSTRATIONS FIO.

xxiii

.... ....

144.

Various applications of the triangular bandage

145.

Various applications of the many-tailed bandages

146.

Methods of fastening the

147.

Bandage

148.

Instruments for the removal of plaster of Paris bandages

149.

Improvised cap and gown

150.

Ordinary chair adapted for improvisation of the Trendelenburg

151.

Lithotomy crutches, or leg holders, for supporting the legs in

152.

Method

153.

Improvised

roller

bantlage

PAGE

388 389

395

397

scissors .

397 401 411

position

412

the lithotomy position

of improvising a lithotomy crutch

Kelly pad

..... ...

412 .

413

TEXTBOOK OF

SURGICAL NURSING

CHAPTER

I

PATHOLOGY The

surgical field

may

be divided into those conditions which

are due to inflammation, injuries, congenital deformities, and

new growths. Into these arbitrary four great divisions modern surgical intervention falls. And since all surgical tervention

is

a greater or lesser degree supplemented by

to

surgical nursing, a thorough

and

intelligent

the underlying pathological conditions

common

the most

Inflammation.

all

in-

field is

is

understanding of

essential.

Perhaps

that of inflammation.

— Inflammation,

according to Grawitz,

may

be

damaged tissues which still The damaging element may be one of several; it may be physical, such as a cut from a knife, a bruise from a stone, or a contusion from a flying timber. It may be chemical, such as a burn with acid, such as nitric, or from caustic alkali. It may be electrical, resulting from touching a "live" wire; or thermal, such as a burn from fire, or a frost bite from the cold; or it may be bacteriological. The last mentioned is

said to be the reaction of irritated

retain vitality.

especially important for five

it

results in

wound

infection.

These

agents then are the exciting factors of an inflammatory

way injured

reaction; they have in some

structure of the body, the

dead and dying

cell,

and

or destroyed the unit

in order to carry off the

replace them, and rebuild the

cells, to

damage

done, the process of inflammation must ensue.

What

is

the process of inflammation?

brief way, wall illustrate

curs

if

croscope

what happens

The

following, in a

grossly,

and what

oc-

the process were to be studied underneath the mi:

If a finger is cut,

dependent upon the

it

bleeds.

size

The amount

of the vessel cut.

clotting, the bleeding ceases

of blood lost

is

In time, due to

and within a few hours the sur3

TEXTBOOK OF SURGICAL NURSING

4

rounding skin may become red, perhaps slightly swollen, and if it is carefully observed as to temperature, it might be some-

what warmer than the adjacent

The wound is said to be examined in sections beneath

skin.

If this process w^ere

inflamed.

a microscope, a very interesting and thoroughly instructive picture would be seen, depending upon the time when the section

was taken. Within a short period after the original injury, there would be along the line of the original incision a clot of Already, (Fig. 1.) blood, and adjacent to it some dead cells. greater stimulated a cells would have of these dead the products blood flow to the part, resulting in a dilatation of blood vessels

and

and an

capillaries,

with white

of the tissues

infiltration

and serum. Naturally, it is this swollen, part red and warm. And as these inmakes the that flammatory products cause an increased pressure on the nerves the wound will become painful in direct proportion to the exublood

red blood

cells,

dation.

has already been noted that

It

Dead

stroyed.

be removed, tissue.

cells,

It is

and the white blood a

known

cells

have been de-

no use to the organism.

tissue is of

fact that

cells

when

carry

off

It

must

the destroyed

cells are injured,

some

which were but slightly traumatized are actually stimulated to growth, and these cells (fibroblasts) immediately begin to reproduce and grow into the blood

clot

along the fibrin strands

(Fig. 2) in an attempt to bridge in the gap caused

struction of the cells killed by the knife. is

de-

barely visible to thr naked eye, but in wounds in which a

definite area of tissue has

been destroyed, or wounds with

nite loss of substance, this

a

by the

In small wounds this

new growth

(Fig. 3.)

Wounds which

minimum amount

of

cuts of the finger.

This

tention.

new growth is known

of blood vessels

Wounds

in

defi-

of cells together wath

as granulation tissue.

are sutured and clean heal with the

granulation tissue and simulate small is

spoken of as healing by primary

which there

is

in-

a loss of tissue from one

cause or another heal by secondary intention, filling in the space

with granulation tissue.

This

takes place in every wound. all

is

the process of healing which

It is

fundamentally

tlie

same

in

clean wounds, whether a cut of the finger, the healing of a

cyst enucleation, or

an incision of the abdomen as a laparotomy.

— PATHOLOGY

B

\

^":-.

v:^;^:^..'' ^' ---•

tI.;^'.-

'.'-''I

•'.^'''•'^''^^'y''

.

•••'•":

•''j-.T'-.V,;^'"-

C

A

-A

A

\Wl

T-^^

•,-*":

-'^i** "T^-;".

•>

Fig.

1.

-

;"-;;j.

-.A^Ar^^T.

Microscopic Drawing of Incised

D

;r":-;'.-

--..:--:

Wound

24

Hours Old.

A,

line of incision; B, blood clot; C, cellular infiltration; D, relative dilatation of blood vessels. Published by permission of the Department of Surgery,

Columbia University.

— TEXTBOOK OF SURGICAL NURSING

^^^

-• Mf?/.U^l:r;

i-'^^-

;..--^'-.:

^^^^

Fig. 2. Microscopic Drawing Illustrating the Growth of Fibroblasts AiiONG Fibrin Strands of the Blood Clot. A, fibrin strands; B. fibroblasts. I'lihlishod by permission of the Deiiartment of Surgery, Columbia University.

— PATHOLOGY The process

is

slightly different, however,

when

the

wound

be-

comes contaminated by bacteria of the pathological variety. In a clean

wound

the

minimum amount

of

damage

is

done

"

'

'

:'

^^

T- a

--- --A :'^.^^'

;*i^'^v..

i-^Sk^

r*^.'

m::^&^^ Fig. 3. Microscopic Drawing of Granulation Tissue. A, fibroblasts; B, newly formed blood vessels. Published by permission of the Department of Surgery, Columbia University.

because the only cells destroyed are those which have been killed

by the knife of the surgeon.

But

if this

knife were not

properly sterilized and were laden with bacteria, the result would be an infected wound (Fig. 4), and the outcome would

TEXTBOOK OP SURGICAL NURSING

oa

PATITOLOGY

\ (

tn